Provider Demographics
NPI:1275679425
Name:TRIUMPH LLC
Entity Type:Organization
Organization Name:TRIUMPH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TALESHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROLLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-256-0824
Mailing Address - Street 1:3210 FAIRHILL DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3215
Mailing Address - Country:US
Mailing Address - Phone:919-256-0824
Mailing Address - Fax:919-256-0833
Practice Address - Street 1:1683B US 401 HWY SOUTH
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-6829
Practice Address - Country:US
Practice Address - Phone:919-496-5827
Practice Address - Fax:919-496-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005385Medicaid
NC6005385Medicaid
2335621Medicare ID - Type Unspecified
NC2335621BMedicare PIN